A Trade Article by Wil Sherman – Advanced Registered Nurse Practitioner
When I first joined the National Fire Protection Association in 1999 my colleagues thought I was reaching just a bit. After all, a nurse with experience as a director of nursing in a large nursing home and a clinical manager in a hospital had better things to do than focus on fire safety, right? Well, yes and no.
Fire safety and patient care go hand in hand as does the logistics associated with proper staffing ratios. Having spent three, (3) decades working with community-based care providers and those who regulate them across America and Canada, I have become intimately aware of certain challenges associated with these smaller, residential business models.
Staffing adequacy is one of them and a frequent source of seriously wavering viewpoints. This is an area that can easily become subjective. The Michigan Adult Foster Care system is a good example. Why?
Typically, the licensing consultant, a state employee, gets to decide if staffing levels are adequate. Seems simple enough. Well maybe. Most licensing consultants are graduate level social workers which means they have human services and quality of life experience; some more than others depending upon their work background. Some are also lawyers.
Many if not most, are not nurses and have not worked in complex neurological settings or Alzheimer’s units as clinicians. Further, unlike states such as Connecticut where public employees including judges and Adult Protective Services workers are required to complete training in the dynamics of Alzheimer’s disease, Michigan has no such law on the books. This can lead to judgment errors that result in accusations of bias or a complete lack of adherence to clinical best practices by licensing personnel.
Note: Admittedly I am not aware of specific internal training licensing personnel are required to complete, however, I cannot find any published requirement for extensive training on Alzheimer’s disease.
For example, in most homes the staffing ratio is one, (1) trained direct care worker to six, (6) residents. This varies with resident need. Often the homes are relatively small, 1200 – 1600 square feet, with bedrooms and bathrooms just a stone’s throw away from the main living and dining areas. With a regular barrage of visitors from therapists to physicians to resident family members, the main areas are often quite busy with responsible adults everywhere, which promotes good people supervision.
Even so, it can be easy to witness a resident in the living room asking for some assistance while the direct care worker is tied up with someone else in a bedroom or bathroom, rarely for more than five, (5) or ten, (10) minutes. The crucial question is whether such an occurrence is a basis for demanding that the staffing ratio be instantly doubled around-the-clock as some licensing personnel are demanding? To that I answer no, based upon the following:
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Residents with advanced dementia or diagnosed Alzheimer’s disease may ask for assistance their entire waking period of the day. In some cases, it’s because they perceive they want more Jell-O. In others, they have a false sense of urgency related to nothing but their deteriorating mind and in others they simply want the presence of a certain person within eyeshot.
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Security is not an issue as most homes – at least those managed by thoughtful professionals – have incredibly loud door alarms which allows the direct care worker to respond promptly in the event of an attempted elopement. For many, limited ambulation prevents an elopement that gives the resident much of a head start.
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Additionally, in most of these business models, the layout allows everyone to be in the same room or general area for the entire day except for bathroom trips. Due to limited concentration ability, group and individual activities may be limited in a home with Alzheimer’s residents which contributes to a more serene environment.
In the apartment models, including those that provide memory care and who agreed to be interviewed for this article, residents are checked on each hour, which is significantly less attention than received in the small group home with only six, (6) residents in a rather small area.
Homes interviewed for this article adhere to staffing of one, (1) direct care worker for every six, (6) to ten, (10) residents based upon a rigorous evaluation including a fall risk assessment.
Often, a provider of residential care who is known for managing a responsible operation enters a productive dialogue about supplemental staffing. Supplemental staffing would be adding personnel at peak hours of operation, often when assisting residents in the morning or during scheduled periods of personal care, i.e. showers; in the dinner hour and 3 – 4 hours during a midnight shift. This can be legally supplemented with a waiver or release of liability form that is signed by residents and/or their designated representatives wherein they acknowledge the current staffing arrangement and agree it is enough – in their judgment – to provide the needed safety for the home.
This allows for a subjective, heavy-handed approach to be avoided by regulators as well as the dark side of these disagreements. What is the dark side?
Because too many licensing departments do not rely upon best practices and tested clinical approaches but instead the judgment of non-nursing and non-physician field personnel, litigation has ensued for loss profits. Why so? Since national referral sources such as A Place for Mom will not refer a new resident to a home with an expired license, a home can be virtually emptied while the dispute drags on. This results in resident displacement and significantly reduced earnings for the home, which may be quite safe. Therefore, the loss profits litigation is pursued.
While nothing written can be absolute in these matters since we are dealing with highly intricate human beings with varying needs, sound reasoning can lead to the kind of compromise that assures safety, quality and attentive care and that complements state administrative rules.
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Another Blog Post by Direct Care Training & Resource Center, Inc. Photos used are to complement the written material. They do not imply an endorsement by or affiliation with any organization nor individual.
